Standardizing communication from acute care providers to primary care providers on critically ill adults.

OBJECTIVE: To increase the frequency of communication of patient information between acute and primary care providers. A secondary objective was to determine whether higher rates of communication were associated with lower rates of hospital readmission 30 days after discharge. METHODS: A validated instrument was used for telephone surveys before and after an intervention designed to increase the frequency of communication among acute care and primary care providers. The communication intervention was implemented in 3 adult intensive care units from 2 campuses of an academic medical center. RESULTS: The frequency of communication among acute care and primary care providers, the perceived usefulness of the intervention, and its association with 30-day readmission rates were assessed for 202 adult intensive care episodes before and 100 episodes after a communication intervention. The frequency of documented communication increased significantly (5/202 or 2% before to 72/100 or 72% after the intervention; P < .001) and the communication was considered useful by every participating primary care provider. Rates of rehospitalization at 30 days were lower for the intervention group than the preintervention group, but the difference was not statistically significant (41/202 or 23% vs 16/88 or 18% of discharged patients; P = .45; power 0.112 at P = .05). CONCLUSIONS: The frequency of communication episodes that provide value can be increased through standardized processes. The key aspects of this effective intervention were setting the expectation that communication should occur, documenting when communication has occurred, and reviewing that documentation during multiprofessional rounds.

Prehospital management of evolving critical illness by the primary care provider.

BACKGROUND: The factors that limit primary care providers (PCPs) from intervening for adults with evolving, acute, severe illness are less understood than the increasing frequency of management by acute care providers. METHODS: Rates of prehospital patient management by a PCP and of communication with acute care teams were measured in a multicenter, cross-sectional, descriptive study conducted in all four of the adult medical ICUs of the three hospitals in central Massachusetts that provide tertiary care. Rates were measured for 390 critical care encounters, using a validated instrument to abstract the medical record and conduct telephone interviews. RESULTS: PCPs implemented prehospital management for eight episodes of acute illness among 300 encounters. Infrequent prehospital management by PCPs was attributed to their lack of awareness of the patient's evolving acute illness. Only 21% of PCPs were aware of the acute illness before their patient was admitted to an ICU, and 33% were not aware that their patient was in an ICU. Rates of PCP involvement were not appreciably different among provider groups or by patient age, sex, insurance status, hospital, ICU, or ICU staffing model. CONCLUSIONS: We identified lack of PCP awareness of patients' acute illness and high rates of PCP referral to acute care providers as the most frequent barriers to prehospital management of evolving acute illness. These findings suggest that implementing processes that encourage early patient-PCP communication and increase rates of prehospital management of infections and acute exacerbations of chronic diseases could reduce use of acute care services.

Cryptococccal meningoencephalitis after H1N1 influenza.

Cryptococcus neoformans is associated with a spectrum of diseases including meningoencephalitis, pneumonia and soft tissue infections. Incidence is higher in immunocompromised hosts like HIV-infected individuals and solid organ transplant recipients. The influenza virus is known to cause immunologic defects. Additionally, the 2009-pandemic H1N1 virus is associated with increased incidence of acute respiratory distress syndrome (ARDS) requiring treatment with systemic steroids. The authors present the first case of cryptococcal meningitis in a patient with flu A-associated ARDS (FLAARDS). In this patient, risk factors for invasive fungal disease included a combination of severe and prolonged H1N1-influenza virus infection, corticosteroid therapy and broad-spectrum antibiotics. While prolonged corticosteroid use is a known risk factor for development of invasive fungal disease, the authors postulate that by causing immunologic defects and FLAARDS, the 2009-pandemic H1N1 virus may represent an additional independent risk for the development of C neoformans meningitis in a previously healthy individual.

Glucagon-induced pheochromocytoma crisis.

OBJECTIVE: To describe a previously asymptomatic woman who developed a glucagon-induced pheochromocytoma crisis during preparation for screening colonoscopy. METHODS: We present the patient's clinical features, laboratory and imaging findings, and outcome and review the related literature. RESULTS: A 76-year-old woman received glucagon to inhibit intestinal motility before routine colonoscopy. She immediately developed severe hypertension, cardiac arrhythmia, and altered mental status. Her hospital course was complicated by encephalopathy and cardiac, respiratory, renal, and hepatic failure. Computed tomography of the abdomen showed a 6.5 × 4.8-cm mass in the left adrenal gland. Biochemical testing for pheochromocytoma revealed markedly elevated plasma catecholamines and metanephrines and urinary vanillylmandelic acid and metanephrine. She underwent a successful laparoscopic left adrenalectomy. Findings from histopathologic and immunohistochemical examination of the adrenal mass were diagnostic of pheochromocytoma. CONCLUSIONS: Glucagon administration induced catecholamine release from an occult pheochromocytoma, which caused multiorgan injury. Health care providers using glucagon must consider this rare, but life-threatening, complication.

Acute renal failure, thrombocytopenia, and elevated liver enzymes after concurrent abuse of alcohol and cocaine.

Cocaine has been associated with known adverse effects on cardiac, cerebrovascular and pulmonary systems. However, the effect of cocaine on other organs has not been extensively reported. A middle age man presented with abdominal pain and nausea after inhalation of crack cocaine. On admission, he was found to be hypertensive and tachycardic. Physical examination revealed mild abdominal tenderness without rebound. Laboratory investigations were significant for acute kidney failure with elevated serum creatinine (3.72 mg/dL), thrombocytopenia (platelet count 74,000/UL), elevated alanine and aspartate transaminases (ALT 331 U/L; AST 462 U/L) and elevated creatine phosphokinase (CPK 5885 U/L). Urine toxicology screening solely revealed cocaine. A clinical diagnosis of cocaine toxicity was made and patient was admitted to the intensive care unit because of multi organ failure. Despite downward trending of liver enzymes during the hospital course, he continued to have residual renal insufficiency and a low platelet count at the time of discharge. In a patient with history of recent cocaine use presenting with these manifestations, cocaine itself should be considered as a likely cause.

Diffuse pulmonary infiltrates in an old man with chronic lymphocytic leukemia.

An 82-year-old man known case of chronic lymphocytic leukemia (CLL) presented with fever and weakness. He had never received any treatment for his CLL in the past. On admission he was found to be in mild respiratory distress with bilateral crackles and had markedly elevated white blood count (WBC) (137 K/uL with 93% lymphocytes). His respiratory status deteriorated necessitating non-invasive ventilatory support. Chest computed tomography (CT) scan revealed bilateral diffuse ground glass opacities, so broad spectrum antibiotic therapy was initiated. Despite that, he remained febrile and cultures were all negative. Chest x-rays showed progressive worsening of diffuse alveolar opacities. Bronchoalveolar lavage (BAL) was negative for infectious etiologies, however flow cytometry of the fluid was consistent with CLL. Chemotherapy with chlorambucil was started. Although most of the pulmonary infiltrates in CLL patients are due to infectious causes, leukemic cells infiltration should be considered as well in CLL patients with respiratory symptoms who do not respond appropriately to standard antimicrobial regimen.